Download CBCT and visual root canal recurrence in treatment of dental pulp

European Review for Medical and Pharmacological Sciences
2017; 21: 903-907
Effects of combining CBCT technology with
visual root canal recurrence in treatment
of elderly patients with dental pulp disease
J.-J. CUI, B. PENG, W. LIN
Department of Endodontics, Hospital of Stomatology, Wuhan University, Hongshan District,
Wuhan, Hubei, China
Abstract. – OBJECTIVE: The aim of this study
is to analyze the effects of combining cone beam
computed tomography (CBCT) technology with
visual root canal recurrence in the treatment of
elderly patients with dental pulp disease.
PATIENTS AND METHODS: 56 cases of elderly patients with dental pulp disease were contiguously selected, and randomly divided into the
control group (70 teeth from 27 patients) and the
observation group (77 teeth from the rest 29 patients). We adopted CBCT technology combined
with conventional root canal therapy in control
group and CBCT technology combined with visual root canal recurrence in observation group
to compare the clinical effects.
RESULTS: It was found that there was no statistical difference in duration of operation between
the two groups (p>0.05). The operation times
and the VAS during and after operation of the
observation group were significantly less than
that of the control group (p<0.05). The duration
of follow-up of the two groups was both about
18 months. Successful rates of treatment for 6
months and by the end of follow-up visit in the
observation group were both significantly higher
than those in the control group (p<0.05). The correct filling rate, good filling rate and fair filling rate
in the observation group were significantly higher than those of the control group (p<0.05).
CONCLUSIONS: CBCT technology combined
with visual root canal recurrence can significantly improve the near and long-term treatment
effects of elderly patients with dental pulp disease.
Key Words:
Cone beam computed tomography, Visual root canal recurrence, Dental pulp disease in the elderly.
Introduction
The incidence rate of dental pulp disease in
the elderly is as high as about 15% to 30%; the
manifestations of the disease mainly include: toothache, cracked tooth, tooth wear, tooth fracture and tooth loss. It seriously influences patients’
chewing and pronunciation function, and reduces their life quality. It is an important reason for
oral infection1. Studies have indicated that the
incidence of the disease may also be related to
chronic gastritis and Alzheimer’s disease2. The
aims of treatment are mainly to preserve the teeth and restore function. Root canal recurrence
is currently recognized as the most effective and
thorough method3. But due to senile dental pulp
disease has unique characteristics such as dental
crown getting shorter, brittleness and increasing
hardness of dental enamel, dentin exposure, gingival atrophy, calcium and deposition of minerals in dental pulp matrix, increasing smallness
of the volume and even blocking of pulp cavity
and root canal, distance of pulp chamber from
the top to the bottom becoming smaller, medullary angle getting lower, root canal getting thinner, apical foramen getting narrower, etc. In such
conditions, the effect of the treatment is often
poor4,5. Studies pointed out that the efficiency
rate for 1 year of conventional root canal treatment of elderly patients with dental pulp disease is 60%-75%, the efficiency rate for 2 years
40%-65%, 5 years 30%-50%6. Conventional root
canal recurrence with ordinary X-ray examination is used to determine the location of the root
canal and the size of padding, which cannot provide multi-angle imaging7. According to hand
feeling, cutting dentin and color of flushing fluid, the effect of root canal filling is judged, which is strongly blind and empirical8. Cone beam
computed tomography (CBCT) technology can
provide a clearer and accurate three-dimensional
imaging and visual root canal recurrence with
the aid of micro operation can significantly improve the filling effect.
Corresponding Author: Bin Peng, MD; e-mail: [email protected]
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J.-J. Cui, B. Peng, W. Lin
Patients and Methods
Patients
We consecutively selected 56 cases of elderly
patients, admitted to our hospital from October
2013 to October 2014, who were diagnosed with
dental pulp disease by X-ray or CBCT. Exclusion
criteria were patients with genuine teeth, false
teeth, carcinoma of gingiva and other oral diseases, hypertension with other diseases, diabetes
and heart disease, not suitable for surgery and incomplete clinical data. The research was accepted by the Ethics Committee in our hospital and
empowered the right of informed consent by the
patients and their families. According to the sequence of admission, the patients were randomly
divided into the control group (70 teeth from 27
patients) and the observation group (77 teeth from
29 patients). In the control group, there were 15
cases of men and 12 cases of women with an age
range of 62 to 75, with an average age of 66.8 ±
9.3 years. The disease duration was 1 month to
1 year, and median time was 4.5 months. There
were 6 cases of acute pulpitis, 16 cases of chronic
pulpitis, 2 cases of acute apical periodontitis, and
3 cases of chronic periapical periodontitis. There
were 16 anterior teeth, 22 premolars, and 32 molars. In the observation group, there were 16 cases
of men and 13 cases of women with an age range
of 60 to 77 and an average age of 68.2 ± 7.7 years.
The disease duration was 1 month to 1.5 years,
and median time was 4.9 months. There were 5
cases of acute pulpitis, 18 cases of chronic pulpitis, 2 cases of acute apical periodontitis, and 4 cases of chronic periapical periodontitis. There were
17 anterior teeth, 25 premolar, and 35 molars. The
differences of gender, age, disease duration, disease types and locations of the teeth in the two
groups had no statistical significance (p>0.05).
Methods
All patients were examined by CBCT (3D
PROMAX imaging system produced by Planmeca Company, Helsinki, Finland). The information
of teeth such as number, location, trend of root
canal, etc. was recorded, and the teeth were well
prepared after disinfection and anti-inflammation.
The control group received conventional root canal recurrence. The mouth and teeth of patients
were cleaned, the medullary cavity was opened
to extract the dead pulp. Afterwards, the root canal was flushed and expanded conventionally. The
length of the root canal was measured by electronic apex locator. The root canal was kept in pre904
paration by step-back technique. The root canal
was flushed repeatedly with saline and chloramines, subsequently, the root canal was dried with
absorbent paper or cotton twist. Afterwards, the
root canal was partly filled with gutta-percha, by
adding root canal paste to fill and seal the pulp
cavity and the root canal orifice.
The observation group received visual root canal
recurrence. It ensured to leave certain space between the lens and the teeth under the microscope. The
focal length was adjusted until the emergence of
a clear field of vision (according to the actual situation, adjust the magnification timely to form the
best field of vision, namely eyepiece and objective
lens are at an angle of 45°). The focal length was
re-adjusted when washing and locating the teeth or
changing the lens. With a clear field of vision, we
used instruments (such as the long stem root canal
instrument) to flush and fill the dental pulp of different diseased teeth. Patients in two groups were
rechecked the effect by CBCT after treatment and
receive several rounds of root canal therapy.
Observational Indexes
The duration of operation, times of operation,
the intraoperative and postoperative visual analogue score (VAS), the success rates of treatment,
filling satisfaction rates of the two groups were
compared. The success rate of treatment was defined as significant relieve of pain. With the aid of
CBCT, it turned out that filling density of tooth
root was appropriate without overfilling or underfilling and periapical shadow completely disappears after the treatment for 6 months. Otherwise,
the treatment was regarded as a failure. The images were reconstructed by 3D CBCT and make
such stipulations as follows. If the distance of the
filler in the root canal from the apical foramen
was longer than 2 mm, it was underfilled. If the
distance was within 2 mm, it was correctly filled.
If the filler goes beyond the apical foramen, it was
overfilled. If the filler in the root canal was closely joined with the root canal wall and distributed evenly without gap, it was good. If the filler in
the root canal is distributed unevenly, or if there
are no more than 2 gaps at one-thirds of the apex
foramen, it was fair. If the filler in the root canal
was distributed unevenly, and there were obvious
gaps between the lateral wall and the apical foramen, it was considered as poor.
Statistical Analysis
SPSS 20.0 statistical software (SPSS Inc., Chicago, IL, USA) was used for statistical record and
CBCT and visual root canal recurrence in treatment of dental pulp disease
Table I. Comparisons of duration of operation, times of operation and VAS.
Group
Duration of Times of
VAS before
operation (min) operation (time) operation (score) Observation group (n=27)
Control group (n=29)
t
p
VAS after
operation (score)
46.7±10.5
1.6±0.5
3.5±0.7
50.3±13.6
1.1±0.3
2.2±0.6
0.6344.478 4.965
0.5520.039 0.036
3.1±0.8
1.4±0.3
5.532
0.027
Table II. Comparison of the success rates.
Group
Treatment for 6 months
Control group (n=27)
Observation group (n=29)
χ2
p
analysis and data was expressed as mean ± standard deviation. The comparison between groups
was made by t-test. The enumeration data were
expressed by percentage (%). The comparison
between groups was made by X2 -test. p<0.05 was
considered to be statistically significant.
Results
Comparisons of Duration of Operation,
Times of Operation and VAS
The comparison of operation duration for the
two groups did not represent any statistical significance (p>0.05). The times of operation and
VAS before and after operation of the observation group were significantly less than those of the
control group (p>0.05) (Table I).
Comparison of the Success Rates
Duration of follow-up to patients in two groups
was both about 18 months. By the treatment for 6
months and up to the end of follow-up, the success
rates of the observation group was significantly
higher than those of the control group (p<0.05)
(Table II).
Comparison of Filling Satisfaction Rates
The correct filling rate, good filling rate and
fair filling rate in the observation group were significantly higher than those of the control group
(p<0.05) (Table III).
End of follow-up
18 (66.7)
15 (55.6)
26 (89.7)
24 (82.8)
4.3894.894
0.0360.027
Discussion
Compared with conventional X-ray film, CBCT
can provide the high-resolution three-dimensional
images (sagittal, axial, and coronary) to carry out
diagnosis analysis of anatomic images of any interested area from different angles and levels. It helps
to show the anatomical structure of pulp cavity
clearly and observe root canal morphology from
different thickness of fault and different angles
according to the need. Especially for elderly patients with complicated root canal systems, CBCT
can identify the morphology, the number and the
trend of the root canal and whether the location of
the root canal in the mesial apex is fused on the
three-dimensional image, etc. CBCT can provide
more image information for preoperative and intraoperative clinical root canal treatment and provide
an important guidance to the diagnosis and treatment of complicated dental pulp diseases10,11. For
the elderly, the distance between the dentine-cementum boundary and the anatomical apex of the
root increased, it even increased to 3-4 mm12. Also,
due to the teeth root of the elderly is fragile, the variation of root canal system was larger, the bending
and stenosis of root canal are more complex, etc.,
the length of work time requires special attention
when preparing root canal for the elderly13. The distance between the roof and floor of elderly pulp
chamber was small and the canal was fine. As a
result of the reparative dentin deposition, it was not
easy to detect root canal orifice and it’s not easy for
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J.-J. Cui, B. Peng, W. Lin
Table III. Comparison of filling satisfaction rates.
Group
Tooth (num) Underfilling
Control group
70
8 (11.4)
Observation group
77
4 (5.2)
F
p
Correct
filling
Overfilling
51 (72.9)
11 (15.7)
69 (89.6)
4 (5.2)
6.983
0.030
Good
filling
Fair
filling
30 (42.9)
28 (40.0)
50 (64.9)
22 (28.6)
4.066
0.044
Bad filling
12 (17.1)
5 (6.5)
Note: *refers to p <0.05 when compared with Group C at same times.
root canal preparation equipment to enter the root
canal directly14. CBCT can provide more valuable
information before and during operation, which
improves the accuracy of root canal treatment.
The microscope in visualization technology
is mainly composed of the microscope eyepiece,
bracket, light source, method system, objective,
etc. Corresponding parameters can be adjusted
(magnification in 2-30 times) according to different types of microscopes clinically. Positioning,
cleaning and forming root canal through visual
root canal recurrence can provide medical staff
with the emission images which are clear and not
distorted. But only the angle of mouth lens needs
to be adjusted during the process of operation and
there is no need to move the microscope15. Visual
root canal recurrence includes a conveyor. The
existence of the conveying device can accurately
convey the flush fluid to the workspace to complete ultrasonic root canal irrigation, remove the pollutants, calcification, plastic compound or broken
equipment of the pulp chamber and root canals,
etc., and make conditions for three-dimensional
filling of root canal16. For the elderly whose tooth
root canal is small and bending even blocked, use
the flexible nickel-titanium instrument combined
with the root canal lubricant (the main ingredient
is ethylene diamine tetraacetic acid) and microscopic ultrasonic technology. By modified double-flared technique, step-down technique under
the crown and balance force method to prepare
a root canal, we can significantly improve the
efficiency and effects of root canal preparation,
improve the success rates of root canal treatment,
reduce the complications after treatment and dive
satisfactory clinical results in treating the partial
closure root canal or tiny calcified root canal17,18.
The results of the research indicated that: there was no statistically significant difference when
comparing the duration of operation of the two
groups. The times of operation and intraoperative
and postoperative VAS of the observation group
were significantly less than those of the control
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group; the difference had statistical significance.
The success rates of the observation group in 6
months’ treatment and 18 months of follow-up
were significantly higher than those of the control group. The correct filling rate, good filling
rate and fair filling rate of the observation group
were significantly higher than those of the control
group; the difference was statistically significant.
Conclusions
To sum up, CBCT technology combined with
visual root canal recurrence can improve the
short-term and long-term therapeutic effects of
elderly patients with dental pulp disease.
Conflict of interest
The authors declare no conflicts of interest.
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